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Background: Sarcoidosis is a granulomatous multisystem disease of unknown etiology and relatively rare. The heterogeneous clinical picture is a diagnostic challenge. We are investigating whether the superficially visible cutaneous lesions can lead to the differential diagnosis of sarcoidosis and what systemic manifestations are present., Material and Methods: As part of our exploratory retrospective investigation (eight years) a total of 32 patients with cutaneous sarcoidosis were identified and analyzed., Results and Conclusion: In many cases the dermatologists considered the differential diagnosis of sarcoidosis even before biopsy (71.8%); in our previous study with ENT-patients the diagnosis wasn't considered in a single case by the attending doctors at this time and without any prevoius suspicion. Sarcoidosis of the skin in the head and neck area is the second most common cutaneous manifestation. After biopsy (Gold standard) the search for further possible organ manifestations is essential (e.g. lungs, heart) to treat them in an early stage and to prevent complications of a possible chronic course (including cardiac arrhythmias, pulmonary fibrosis)., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Objective: Epistaxis in children is one of the most common causes for seeking professional medical help. Patients may be treated by several disciplines with various approaches to pediatric epistaxis. We reviewed cases of pediatric epistaxis from an otorhinolaryngologist's point of view., Methods: A retrospective chart review was performed on all patients younger than 18 years presenting with epistaxis to the Department of Otorhinolaryngology at the University of Bonn, Germany., Results: Sixty episodes of epistaxis in 58 patients were included in the study. Mean age was 10.1 ± 4.5 years. In terms of risk factors, 3 patients had a hemorrhagic diathesis, 3 had taken medication that interfered with hemostasis, and 8 had a history of previous trauma, most of which was digital manipulation. Twenty-six patients did not need invasive therapy. Twenty-six patients received cauterization to control the bleeding, and 4 patients needed surgery. The necessity for surgery was mainly noncooperation., Conclusions: Epistaxis in children is seldom serious. However, hemorrhagic diathesis needs to be kept in mind as a potential cause of epistaxis. In most cases, careful instruction of the patients and the relatives concerning nasal mucosal care is sufficient. If cauterization is necessary, silver nitrate coagulation should be preferred over electrocoagulation., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Sarcoidosis is a multisystemic granulomatous disease of unknown cause which affects the lung or bilateral hilar lymphadenopathy in over 90% of the cases. Neurosarcoidosis (NS) is rare and accounts for approximately 5 - 15% of the cases. Involvement of all parts of the central and peripheral nervous system is possible with various clinical symptoms, e. g. seizures, hydrocephalus, optic/facial nerve palsy or hearing loss. Methods: We screened the neuropathological data bases and the medical records of two neurosurgical university hospitals for cases of NS. All these cases had been verified by surgical biopsy. We retrospectively evaluated the patient's records with special regard to the histopathology reports and specific clinical symptoms. Results: We identified 9 cases of NS between 1994 and 2014 (3 female, 6 male patients). The average age at the time of diagnosis of NS was 41,4 years. Various clinical symptoms like hydrocephalus ( n  = 3), seizures ( n  = 1), meningitis ( n  = 1), optical nerve involvment with vision disorder ( n  = 1), myelitis with paraplegia ( n  = 1), mastoiditis with hearing loss ( n  = 1), back pain syndrome ( n  = 2) were present. 7 patients were treated with corticosteroids, 1 patient with cyclophosphamide and 1 with a combination of corticosteroids and methotrexate. Conclusion: NS is a rare but potentially life-threatening disease. It is difficult to distinguish sarcoidosis from other granulomatous diseases, infectious diseases like tuberculosis, multiple sclerosis or neoplasm. For a definite diagnosis, a neurosurgical biopsy with histological evidence of noncaseating epithelioid cell granulomas is required, followed by multidisciplinary treatment.

Objective/Hypothesis: Spontaneous rhinoliquorrhea often occurs due to defects of the skull base. It is often misinterpreted as rhinitis and is surgically the most difficult rhinoliquorrhea entity to close. Methods: We conducted a retrospective chart analysis of patients that were diagnosed with spontaneous rhinoliquorrhea at the University Hospital Bonn between 2001 and 2017. Results: Overall, twelve patients were included in this study. On average, the time between occurrence of nasal discharge and diagnoses of rhinoliquorrhea was 123 days. In ten patients, the localization of the skull base defect could be localized by computed tomography or MRI cisternography. Ten patients underwent surgery, of which 9 remained recurrence free. One patient underwent revision surgery and from thereon was recurrence free. Conclusion: Spontaneous rhinoliquorrhea still remains a diagnostic and therapeutic challenge. Whenever persistent watery nasal discharge appears in a patient, rhinoliquorrhea must be considered. Endoscopic surgical reconstruction of the skull base is the therapeutic gold standard and should be attempted as soon as the diagnosis is secured., Competing Interests: The authors declare that they have no competing interests.

Background: Sarcoidosis is a chronic disease, which predominantly affects the lung. Since sinonasal sarcoidosis is rare, little is known about the sarcoidosis manifestation at this site. Therefore, the aim of our study was to detect the prevalence of sinonasal sarcoidosis, its clinical occurrence, diagnosis, and therapy., Methods: The database of all patients having visited the otorhinolaryngology departments of the universities in Göttingen and in Bonn between 2003 and 2016 was searched for the diagnosis of sinonasal sarcoidosis., Results: Thirteen patients with a biopsy-proven sinonasal sarcoidosis were identified. Most patients presented non-specific clinical symptoms, which are also found in acute and chronic sinusitis. None of the patients was suspected to have sinonasal sarcoidosis by the ENT doctor before histological validation. The mean diagnostic delay was 262 (± 195) days. An additional pulmonary involvement was detected in four of six patients., Conclusions: Sinonasal sarcoidosis is presenting with heterogeneous clinical presentations. An early biopsy of granulomatous lesions is mandatory. A multidisciplinary approach is needed to exclude serious lung or heart manifestations, because even asymptomatic organ involvement is possible. A CT-scan may be useful even if unspecific. Local or systemic therapy has to be prepared individually using local and systemic corticosteroids, antimetabolites, or anti-TNF-alpha.

Objectives/hypothesis: Salivary fistulas are a common minor complication of parotid surgery. botulinum toxin has repeatedly been reported to be an adequate treatment of this entity. To date, there is little scientific evidence for clinical decision making after appearance of a salivary fistula., Study Design: Retrospective chart analysis of 16 patients who had been treated with botulinum toxin for salivary fistula., Methods: All patients who had been treated for salivary fistula at a tertiary referral hospital from 2010 to 2016 were included. Patient files were used to obtain characteristics of patients, treatment, and follow-up., Results: Sixteen patients with salivary fistula received 27 injections of botulinum toxin. Nine patients required one injection for the fistula to heal, five patients needed two injections, and one patient needed three and four injections, respectively. No patient underwent additional surgery or radiotherapy. We observed no adverse effects in any patient treated with botulinum toxin., Conclusions: In most cases of salivary fistula, injections of botulinum toxin are a valid treatment. If the initial injection is not successful, injections may be repeated once. Otherwise, revision surgery should be considered. In general, treatment with botulinum toxin should be commenced in an earlier stage and with higher dosages., Level of Evidence: 4 Laryngoscope, 129:403-408, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Epistaxis is one of the more common reasons for emergency room visits. The main risk factor for epistaxis is anticoagulant therapy. Until recently, the main culprit was oral intake of a vitamin K antagonist, such as warfarin, which has a number of side effects. Even more recently, several direct oral anticoagulants, rivaroxaban and dabigatran, have been approved for use. We investigated the possible differences between treatment of epistaxis with direct oral anticoagulants and vitamin K antagonists., Methods: We conducted a retrospective cohort study at a tertiary referral center in Germany. All patients who were admitted within a 1-year period were included. Patient files were used to obtain the information., Results: Overall, 677 patients were included in our study. Of these, 159 had been treated with vitamin K antagonists and 49 with direct oral anticoagulants. There were no significant differences in terms of age (p = 0.592), sex (p = 0.372), vital signs, bloodwork, or location of bleeding (p = 0.372). Management of epistaxis between the groups was also comparable (p = 0.399), with similar hospital admission rates (37.1% vs 24.5%; p = 0.145) and duration of stay (3.5 ± 2.1 days vs 3.8 ± 3.3 days; p = 0.650)., Conclusion: We found no evidence to suggest epistaxis is more severe or requires more invasive therapy in patients given direct oral anticoagulants. A significant proportion of patients on vitamin K antagonists were not within the target range for international normalized ratio, highlighting one of the main issues with oral anticoagulation by vitamin K antagonists., (© 2018 ARS-AAOA, LLC.)

Background: Having one hand occupied with the endoscope is the major disadvantage for the surgeon when it comes to functional endoscopic sinus surgery (FESS). Only the other hand is free to use the surgical instruments. Tiredness or frequent instrument changes can thus lead to shaky endoscopic images., Methods: We collected the pose data (position and orientation) of the rigid 0° endoscope and all the instruments used in 16 FESS procedures with manual endoscope guidance as well as robot-assisted endoscope guidance. In combination with the DICOM CT data, we tracked the endoscope poses and workspaces using self-developed tracking markers., Results: All surgeries were performed once with the robot and once with the surgeon holding the endoscope. Looking at the durations required, we observed a decrease in the operating time because one surgeon doing all the procedures and so a learning curve occurred what we expected. The visual inspection of the specimens showed no damages to any of the structures outside the paranasal sinuses., Conclusion: Robot-assisted endoscope guidance in sinus surgery is possible. Further CT data, however, are desirable for the surgical analysis of a tracker-based navigation within the anatomic borders. Our marker-based tracking of the endoscope as well as the instruments makes an automated endoscope guidance feasible. On the subjective side, we see that RASS brings a relief for the surgeon.

Background: Despite the controversial international debate on the use of metamizole as a standard analgesic, the prescription figures for Germany have increased constantly during recent years. However, metamizole can lead to the rare and severe medical condition called agranulocytosis., Materials and Methods: Between January 2009 and January 2014, 5 patients with metamizole-induced agranulocytosis presented themselves at the Interdisciplinary Emergency Center of the University Clinic Bonn. According to their leading ENT symptoms, they were transferred to the otorhinolaryngological department. We retrospectively evaluated metamizole medication, all general patient data and previous diseases, as well as disease course and the respective therapies., Results: Within the scope of the different treatments--surgery after trauma (n=2), elective orthopedic surgery (n=2), tonsillitis treatment (n=1)--the patients (n=5; mean age 30 years) had made regular ambulant use of metamizole for several days or weeks (4-28 days, mean 16.8 days). Daily oral dose ranged from 625 to 2000 mg/d (mean 1500 mg/d). Subsequently, patients required treatment for clinical symptoms of agranulocytosis (e.g. tonsillitis with severe odynophagia and significantly reduced general condition). All patients were monitored in an intermediate or intensive care unit (3-14 days, mean 10 days). No patients died., Discussion: As our cases show, when using metamizole as a standard analgesic, the treating otolaryngologist should look for clinical symptoms of agranulocytosis and inform patients about possible adverse effects. We recommend strict indication setting, regular blood analyses during long-term medication and consideration of alternative analgesics (e.g. NSAR).

Background: For the further development of robot-assisted endoscope guidance in functional endoscopic sinus surgery (FESS), ground data about the workspaces and endoscope movements in conventional FESS are needed., Methods: Applying a self-developed marker-based tracking system, we collected the pose data (position and orientation) of the endoscope and all other instruments used in five real sinus surgeries., Results: The automated segmentation of the endoscope poses shows the shape of a hourglass, with a pivot region or pivot point at the 'waistline' of the hourglass, close to the nasal entrance in the nasal dome., Conclusion: We were able to identify a pivot point at the waistline of the segmented endoscope poses. The size of the pivot point corresponds with the diameter of the 4 mm endoscope. Because of the reduction to four degrees of freedom for endoscope motions (three rotations and one translation), easier and safer robot-assisted endoscope guidance becomes feasible., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background: Rhinoliths are rare affections of the main nasal cavity and the paranasal sinuses. Initially, as a result of their low incidence, they are often incorrectly classified as calcified tumors in clinical examination., Methodology: We have identified three cases in our patient population and evaluated the clinical symptoms as well as the pathological findings and the causes of the disease., Results: Due to their extension and the respective clinical pattern, all masses were surgically removed under endotracheal anesthesia. The histopathological findings comprised an ectopic tooth, a vegetable (most likely a leaf from the garden) as well as a textile foreign body (probably of iatrogenic origin)., Conclusion: Undiscovered foreign bodies of the main nasal cavity are a common cause for the formation of rhinoliths. We have also displayed the respective incidence and the therapeutic options.

Background: Nasopharyngeal carcinoma (NPC) is a rare tumor entity in Germany in contrast to endemic countries in Asia or Africa. This retrospective study investigated patient characteristics and prognostic factors with respect to different NPC treatment strategies., Patients and Methods: A total of 63 NPC patients treated during the period 1990-2009 at the University Hospital Bonn, Germany, were included., Results: The median age of the patients was 56.4 years, the male:female ratio was 3.2:1, 23.8% were in Union Internationale Contre le Cancer (UICC) stage I/II and 76.2% were in stage III/IV. Most of the carcinomas were WHO type III (57.1%), followed by World Health Organization (WHO) type II (33.3%) and at last WHO type I (9.6%). The 5-year overall survival rate after concomitant chemoradiotherapy (RCT) was 75% and after radiotherapy (RT) 60%. The mortality rate increased by 3.5 times with each increase in T-stage (p ≤ 0.047). The recurrence rate (RR) after RCT was 34% and after RT alone 68% (p ≤ 0.04). Tumor ablation increased the RR significantly (p ≤ 0.047)., Conclusion: Combined chemotherapy and RT is an effective treatment of NPC disease and clearly superior to RT alone. Tumor ablation before RCT/RT worsens the prognosis and is now obsolete.

Background: Otorhinolaryngologists require new diagnostic methods to give further insight into the physiology of nasal breathing. The functional aspects of radiological data in the field of ENT have rarely been examined. This study compares computed tomography (CT) scan area measurements of the paranasal sinuses with physiological data from rhinomanometry., Patients and Methods: In a retrospective study, paranasal CT scans from 36 patients were analysed for volume, width and hydraulic diameter of the five key regions of the nasal cavity (CT rhinometry) and compared to the active anterior rhinomanometric (RMM) results representing the gold standard in nasal flow description., Results: The highest correlation between the rhinomanometric results and CT rhinometry was found at the internal ostium, followed by the diffuser region. The structures important for regulating nasal flow could thus be identified in the CT area data., Conclusion: CT rhinometry revealed structures important for nasal breathing, in addition to providing anatomical and topographical data. CT rhinometry measured volumes, width and hydraulic diameters of the nasal cavity correlated with measurements of transnasal flow.

Background: With a worldwide annual incident rate of 1/200,000 sinonasal tract malignancies are a relatively rare disease., Material and Methods: All patients with sinonasal malignancies (n = 177) treated between 1996 and 2010 at the Department of Head and Neck Surgery, University of Bonn, Germany were analyzed retrospectively. Data on age, gender and incidence were available for all patients but other demographic data, treatment regimes and outcome were only analyzed for carcinomas., Results: Carcinomas were the most frequent histological diagnosis (58%). Unspecific sinonasal symptoms lasted on average for 4.7 ± 5 months before primary diagnosis. Interestingly, 64% of patients with sinonasal carcinoma presented with locally advanced disease (T3-4) but only 15% displayed corresponding regional lymph node metastases. The overall 3-year survival rate was 61%. Patients solely needing surgical treatment displayed a better survival rate than patients receiving combined surgery and adjuvant treatment or definitive radio(chemo)therapy. Multivariate analysis revealed a T-stage classification as the only independent prognostic factor for 3-year survival., Conclusions: Due to unspecific symptoms most sinonasal malignancies are diagnosed at an advanced stage of the disease and despite multimodal therapies these tumors still have an unfavorable prognosis.

Functional Endoscopic Surgery of Paranasal sinuses (FESS) and Skull Base surgery is one of the most frequent surgeries performed at the ENT department of the Bonn University, Germany. Beside of surgical Navigation Robotic is one of the upcoming fields of Computer assisted Surgery developments. This work presents novel research and concepts for Robot Assisted Endoscopic Sinus Surgery (RASS) of the Paranasal sinuses and the anterior Skull Base containing the analysis of surgical workflows, the segmentation and modelling of the Paranasal sinuses and the anterior Skull Base and the development of the robotic path planning. An interdisciplinary group of software engineers and surgeons in Braunschweig and Bonn, Germany are approximate to solutions by a clinical and technical research program financed through the DFG (Deutsche Forschungsgemeinschaft, German research Community).

Manual segmentation of computed tomography (CT) datasets was performed for robot-assisted endoscope movement during functional endoscopic sinus surgery (FESS). Segmented 3D models are needed for the robots' workspace definition. A total of 50 preselected CT datasets were each segmented in 150-200 coronal slices with 24 landmarks being set. Three different colors for segmentation represent diverse risk areas. Extension and volumetric measurements were performed. Three-dimensional reconstruction was generated after segmentation. Manual segmentation took 8-10 h for each CT dataset. The mean volumes were: right maxillary sinus 17.4 cm(3), left side 17.9 cm(3), right frontal sinus 4.2 cm(3), left side 4.0 cm(3), total frontal sinuses 7.9 cm(3), sphenoid sinus right side 5.3 cm(3), left side 5.5 cm(3), total sphenoid sinus volume 11.2 cm(3). Our manually segmented 3D-models present the patient's individual anatomy with a special focus on structures in danger according to the diverse colored risk areas. For safe robot assistance, the high-accuracy models represent an average of the population for anatomical variations, extension and volumetric measurements. They can be used as a database for automatic model-based segmentation. None of the segmentation methods so far described provide risk segmentation. The robot's maximum distance to the segmented border can be adjusted according to the differently colored areas.

Manual segmentation is often used for evaluation of automatic or semi-automatic segmentation. The purpose of this paper is to describe the inter and intraindividual variability, the dubiety of manual segmentation as a gold standard and to find reasons for the discrepancy. We realized two experiments. In the first one ten ENT surgeons, ten medical students and one engineer outlined the right maxillary sinus and ethmoid sinuses manually on a standard CT dataset of a human head. In the second experiment two participants outlined maxillary sinus and ethmoid sinuses five times consecutively. Manual segmentation was accomplished with custom software using a line segmentation tool. The first experiment shows the interindividual variability of manual segmentation which is higher for ethmoidal sinuses than for maxillary sinuses. The variability can be caused by the level of experience, different interpretation of the CT data or different levels of accuracy. The second experiment shows intraindividual variability which is lower than interindividual variability. Most variances in both experiments appear during segmentation of ethmoidal sinuses and outlining hiatus semilunaris. Concerning the inter and intraindividual variances the segmentation result of one manual segmenter could not directly be used as gold standard for the evaluation of automatic segmentation algorithms.

Background: To relieve the surgeon during functional endoscopic endonasal sinus surgery (FESS), the endoscope should be guided by autonomous robot assistance. The surgeon will thus have two hands free for suctioning and manipulation during FESS., Patients/methods: With a force/torque sensor mounted on the endoscope, we measured forces in six degrees of freedom in five cadaver heads and in 20 actual endoscopic sinus procedures. On the cadaver heads we performed complete endoscopic endonasal dissection of all paranasal sinuses. All forces at the endoscope were monitored continuously., Results: The mean forces occurring at the endoscope were 3.2 N. There were only slight differences between the in vivo and ex vivo data. We measured peak forces up to 25.2 N. In 95% of all cases, forces were lower than 7 N., Conclusion: Forces up to 7 N are sufficient for endoscopic guidance during FESS. Peak forces are distinctive for endoscopic guidance by humans and could be optimised by sensor-based intraoperative robot guidance. Higher forces are required for surgical endoscopy of the frontal and maxillary sinuses compared with the ethmoid sinuses.

Hypopharyngeal perforation is a rare but dangerous complication caused by diagnostic procedures. If there is any suspicion of perforation of the upper airways and/or upper digestive tract, immediate diagnostic and therapeutic procedures are indicated. Possible complications of a hypopharyngeal perforation are deep neck infection with subsequent mediastinitis and haemorrhage from major cervical vessels, both of which have high mortality rates. We present the case of a 65 year old male patient with perforation of the hypopharynx after transesophageal echocardiography which was unrecognized for more than 1 week. Clinical symptoms of hypopharyngeal perforation may initially be unspecific. Esophagography (Gastrografin administration) and computed tomography as well as esophagoscopy are needed to certify the diagnosis and to evaluate the extent of the lesion. Pathological findings as well as diagnostic and therapeutic needs are demonstrated and discussed.

We report the case of an extranodal non-Hodgkin's lymphoma mimicking a benign tumor in the left parotid gland of a 71-year-old woman. The clinical presentation of the painless, mobile mass was suggestive of a benign parotid tumor such as an adenoma. The intraglandular tumor appeared sonographically as a well-circumscribed, hypoechoic, homogeneous, lobulated mass with mild distal sound enhancement. Power Doppler sonography showed marked intratumoral vascularization. The tumor was resected by lateral lobectomy of the parotid gland and was found histopathologically to be a diffuse large B-cell lymphoma., (Copyright 2002 John Wiley & Sons, Inc.)

The plant-pathogen fungus Trichothecium roseum produces in vitro as well as in vivo the toxic metabolites trichothecin, trichothecolone and rosenonolactone. Trichothecin is cytotoxic and inhibits the alcoholic fermentation. It is not metabolized by yeast during the alcoholic fermentation. All toxins showed a minor biological activity against microorganisms other than yeast. Trichothecin caused a bitter taste in wine at higher toxin concentrations (greater than 5 mg/l). Trichothecin was detected in a few samples of wine of higher quality.